Pennsylvania Department of Health
FOULKEWAYS AT GWYNEDD
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FOULKEWAYS AT GWYNEDD
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
FOULKEWAYS AT GWYNEDD - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 060902
Component 01
Gwynedd House

Based on a Relicensure Survey completed on December 19, 2023, it was determined that Foulkeways at Gwynedd was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.

This is a two-story, Type II (111), protected non-combustible building, with a basement and unused attic, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies:State only Deficiency.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:
* They are not intended to serve four or more inpatients.
* They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
* The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common wall separations, affecting one of two common walls.

Findings include:

Observation on December 19, 2023, at 11:30 a.m., revealed the basement fire doors separating Skilled/PC failed to fully close and latch when tested.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed common wall deficiency.






 Plan of Correction - To be completed: 03/15/2024

Door closer on basement fire door separating Skilled/PC was adjusted to close fully and latch when released on day of survey.

Director of Facilities or designee will audit on a quarterly basis, all magnetic release hallway doors in Gwynedd House to ensure the doors fully close and latch

Director of Facilities or designee will audit on a quarterly basis all fire doors to ensure that they fully close and latch when tested.

Copies of audits will be brought to the quarterly QAPI meeting for review.

Outside contractor, "Life Safety Services", annually tests and reports compliance on all doors to the Director of Facilities or designee. They are scheduled for their next annual testing in March 2024.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
NFPA 101 STANDARD Emergency Lighting:State only Deficiency.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review, and interview, it was determined the facility failed to maintain its emergency lighting, affecting one of two levels.

Findings include:

Document review on December 19, 2023, at 9:30 a.m., revealed the facility lacked documentation of the following required tests of the battery back-up lighting:

a. monthly 30-second testing.
b. annual 90-minute test.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the missing documentation.






 Plan of Correction - To be completed: 03/15/2024

Generator logs were updated for use in Jan 2024 that added annual 90 minute and monthly 30 second test of battery back-up lighting.

Director of Facilities or designee will audit logs on a quarterly basis to ensure compliance.

Copies of audits will be brought to the quarterly QAPI meeting.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
NFPA 101 STANDARD Hazardous Areas - Enclosure:State only Deficiency.
Hazardous Areas - Enclosure
2012 EXISTING
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in sprinklered locations, affecting one of two levels.

Findings Include:

1. Observation on December 19, 2023, at 11:10 a.m., revealed the first floor Soiled room door had excessive gap, latch side of door.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the door deficiency.




 Plan of Correction - To be completed: 03/15/2024

Door closer and latch of the first-floor soiled room door was replaced to ensure door closed properly on 01/05/24.

Hazardous areas protected by fire barrier will be audited to ensure closer and latches are functioning properly by the Director of Facilities or Designee.

Copies of audits will be brought to the quarterly QAPI meeting.

Annual door survey will review all doors in Gwynedd House to ensure compliance with fire code and be overseen by Director of Facilities or designee. The contractor, "Life Safety Services", is scheduled for the annual review in March 2024.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:State only Deficiency.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain fire alarm system components, affecting the entire facility.

Findings include:

Document review on December 19, 2023, at 9:30 a.m., revealed the December 5, 2023, Fire alarm inspection listed 2- failed heat detectors, zone 3. Corrective action was not available at time of survey.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the deficiency.




 Plan of Correction - To be completed: 03/15/2024

Siemens identified failures during testing in November 2023. Siemens is scheduled for maintenance on site in January 2024.

Siemens will resolve and test repair. Director of Facilities or designee to ensure corrective action has been taken.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:State only Deficiency.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Document review on December 19, 2023, at 9:30 a.m., revealed the September 5, 2023, sprinkler inspection report listed the following deficiency, evidence of corrective action was not available at time of survey:

a. Low air switch found not connected to FACP at time of inspection.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the sprinkler system deficiency.

2. Observation on December 19, 2023, at 11:05 a.m., revealed, the first sprinkler room by room 19, lacked a sprinkler wrench.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the missing sprinkler wrench.




 Plan of Correction - To be completed: 03/15/2024

Facility brought this issue to sprinkler vendor, Tilley's Fire Solutions attention. In October 2023, pressure switch was tied into Siemens fire alarm system by onsite electrician and tested. All other dry sprinkler systems previously had low air notifications tied into alarm system and were functional as confirmed by vendor and Director of Facilities or designee.

Sprinkler vendor tested system #3 low air switch during quarterly testing on December 29, 2023 and was found to be fully functional.

Director of Facilities or designee, will ensure sprinkler vendor tests low air switch and alarm system integration during ongoing quarterly testing.

Copies of testing reports will be brought to the quarterly QAPI meeting.

New sprinkler wrench was replaced and labeled to prevent wrench from being removed from Sprinkler Room.

All sprinkler rooms were audited to ensure wrenches were available in each sprinkler room.

Copies of the audit will be brought to the quarterly QAPI meeting.

Director of Facilities or designee, will audit sprinkler rooms annually to ensure wrench is available in each sprinkler room.


Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:State only Deficiency.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two levels.

Findings include:

Observation on December 19, 2023, at 11:40 a.m., revealed, on the first floor, above the smoke doors by room 15, an unsealed penetration around data wires.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the penetration.




 Plan of Correction - To be completed: 03/15/2024

Fire caulk, 3M CP 25 WB+ was used to seal the penetration around data wires above the smoke doors by room 15 on 1/10/24.

Director of Facilities or designee will check all penetrations above fire doors and seal with approved fire rated caulk to ensure smoke barrier walls are free of unsealed penetrations.

Director of Facilities or designee, will re-educate facilities staff on maintaining smoke barrier walls of unsealed penetrations.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
NFPA 101 STANDARD Electrical Systems - Other:State only Deficiency.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two floors.

Findings include:

Observation on December 19, 2023, at 11:50 a.m., revealed, in basement boiler room, 3- junction boxes were missing cover plates, exposing the inner wiring.

Exit interview with the Administrator and Maintenance Director on December 19, 2023, at 12:15 p.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.





 Plan of Correction - To be completed: 03/15/2024

Original cover plates for 3 electric junction boxes were replaced in basement boiler room on 12/20/23.

Director of Facilities or designee audited remaining mechanical rooms junction boxes to ensure covers were installed where indicated.

Director of Facilities or designee will bring copy of audit to quarterly QAPI meeting.

Director of Facilities or designee will educate facilities staff to immediately replace junction box covers after work is completed.

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

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